Coding for surgical services can be complicated due to the numerous rules, guidelines, and exceptions—all of which the Centers for Medicare & Medicaid Services frequently updates and revises. Consequently, the American College of Surgeons (ACS) General Surgery Coding and Reimbursement Committee (GSCRC) often receives questions about coding, particularly for breast surgery. This column responds to some frequently asked coding questions related to breast cancer operations, sentinel node biopsy, ultrasound-guided core biopsies, excision with wires, intraoperative assessment of margins, and more.
Why are there two separate codes to report for breast cancer operations with sentinel node biopsy and one unified code for mastectomy or lumpectomy with axillary node dissection?
The breast surgery Current Procedural Terminology (CPT) codes were developed when axillary dissection was standard therapy for breast cancer. Modified radical mastectomy is coded 19307; lumpectomy with axillary dissection is coded 19302. When sentinel lymph node biopsy was developed, the code needed to be applied to both breast and melanoma procedures. Code 38900 is an add-on code to be used with any lymph node biopsy or lymphadenectomy code to indicate the intraoperative work done to identify the sentinel lymph nodes. Therefore, lumpectomy with sentinel node biopsy is billed using codes 19301, 38525-51, and 38900. Total mastectomy with sentinel node biopsy uses codes 19303, 38525-51, and 38900.
When a total mastectomy with sentinel node biopsy is performed, I obtain a frozen section of the nodes and proceed to dissect the axilla if positive. Can I use multiple codes for this procedure?
This is a modified radical mastectomy (19307) with sentinel node mapping procedure (38900). The axillary node biopsy cannot be reported separately from the axillary dissection.
Can I code for injection of radioactive tracer and blue dye for sentinel lymph node biopsy?
If you preoperatively inject radioactive tracer, report 38792. Injection of blue dye, when performed, is included in the sentinel node code, 38900.
I perform ultrasound-guided core biopsies but do not leave localization devices in the biopsy location. Should I use codes 19083 and 19084?
Yes. All of the image-guided biopsy codes, 19081–19086, specify that the biopsy is inclusive of the placement of breast localization devices, including clips and metallic pellet when performed, and imaging of the biopsy specimen, when performed. In other words, you cannot report separately for clip placement or specimen imaging, but that the code is appropriate for the biopsy regardless of whether clip placement or specimen imaging are included.
Do you code differently for excision with multiple wires for localization than with one wire?
The new image-guided localization codes are per lesion, not per wire. Multiple wires may be placed to identify any lesion. An excision may only be reported once through a single incision, regardless of the number of wires used for the localization.
How do you code for excision of additional tissue for margins at the time of lumpectomy? Is there a code for the added work of orienting and inking margins?
CPT codes 19120 and 19125 are used for excision of breast lesions, where attention to surgical margins and assurance of complete tumor resection is unnecessary. Oncologic resection with attention to margins (lumpectomy or partial mastectomy), code 19301, describes the procedure where margin status is indicated by any method and may include excision of additional surrounding tissue for margins. As a corollary, use code 19301 whether the breast cancer is palpable or is removed with preoperative placement of a localization wire.
How do you code re-excision of a lumpectomy cavity when you must return for positive margins on final pathology a week after a lumpectomy?
Use code 19301-58 for lumpectomy with modifier for “staged/related procedure in the postoperative period.” Indicate in the operative report that this procedure is a planned return to the operating room for a more extensive work.
Could I code for the X ray of the operative specimen with CPT code 76098?
For all image-guided breast excisions, the radiographic evaluation of the specimen is bundled into the localization procedure, and should not be coded separately.
How would I code for intraoperative assessment of margins, for instance, with radiofrequency spectroscopy?
There is no specific CPT code for reporting intraoperative assessment of margins by any particular method, such as preparing touch-prep or frozen specimens, which are considered integral to the work of a lumpectomy for malignancy (CPT code 19301). Intraoperative guidance with ultrasound imaging for assessment of margins can be reported (CPT code 76998) only if permanent images are obtained and saved, and an ultrasound report is entered into the medical record.
How should I code for nipple-sparing mastectomy and skin-sparing mastectomy to distinguish them from total mastectomy?
All of these procedures are classified mastectomy for cancer and should all be coded with 19303. No special distinctions are made for the type of incision. The operative report should use the wording “total nipple-sparing” or “total skin-sparing” mastectomy to avoid confusion with a subcutaneous mastectomy.
How do you code for intraoperative radiation or placement of the different devices for brachytherapy?
At present, no code has been designated for intraoperative radiation treatment of the breast. Codes for placement of brachytherapy catheters are available and can be used regardless of the brand (Mammosite, SAVI, Contura, and so on). These codes are 19296 for delayed insertion and 19297 for immediate insertion at the time of lumpectomy.
How do you code for ablation of breast lesions with cryotherapy, microwave, RFA, or laser?
The Food and Drug Administration (FDA) has not approved ablation of breast lesions with cryotherapy, microwave, or radiofrequency ablation (RFA), or laser for treatment of breast cancer. The CPT code for cryotherapy of fibroadenomas is 19105. The FDA has also approved laser ablation of fibroadenomas, but a CPT code has yet to be established. RFA and high-frequency microwave ablation are considered investigational.
If you have questions or comments regarding this column, contact Sarah Kurusz, ACS Practice Affairs Associate, at firstname.lastname@example.org or 202-672-1505. If you have additional coding questions, contact the ACS Coding Hotline at 800-227-7911 between 8:00 am and 5:00 pm, CST, excluding holidays.
Accurate coding is the responsibility of the provider. This summary is only a resource to assist in the billing process.